Basic Information
| Provider Information | |||||||||
| NPI: | 1619907797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTWAL | ||||||||
| FirstName: | MAHESH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 N 24TH ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022564628 | ||||||||
| FaxNumber: | 6029579438 | ||||||||
| Practice Location | |||||||||
| Address1: | 4722 N 24TH ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022564628 | ||||||||
| FaxNumber: | 8558514319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 11968 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 11968 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 283872-05 | 05 | AZ | MEDICAID |